CMS Proposes Raising Medicaid Payments to Primary Care Physicians

In a proposed rule announced on Wednesday, CMS seeks to provide states more than $11 billion in new funds to improve Medicaid primary care from 2013 through 2014. The proposal, if finalized, would implement requirements of the Patient Protection and Affordable Care Act designed to help primary care physicians and networks prepare for the increased enrollment following implementation of healthcare reform. Assuming the Affordable Care Act is not declared unconstitutional by the Supreme Court this summer, CMS will likely finalize the rule later in the year. The Affordable Care Act requires that Medicaid reimburse certain primary care specialties, including family medicine, general internal medicine, and pediatric medicine, at the levels of Medicare reimbursement for calendar years 2013 and 2014. This increase in payment is entirely funded by the federal government and States will not need to provide matching payments. Currently, the national average Medicaid payment rate is only two-thirds of what Medicare pays. In Delaware, the payment rate is 54% and below, according to data published by American Medical News. Some physicians are expressing concern about what will happen after 2014 to practices that accept more patients during the pay increase. Once the payment rates return to current numbers after 2014, will primary care practices suffer the consequences of taking in a larger patient population with lower paying insurance? The rule can be read here. (http://www.ofr.gov/OFRUpload/OFRData/2012-11421_PI.pdf)Comments are due June 11th.

Delaware Focused on Cutting Medicaid Costs

In these tough economic times, courts across the country have been addressing challenges to State action aimed at reducing Medicaid costs. In October, the US Supreme Court heard argument (but has not yet issued a decision) in Douglas v. Independent Living Center to answer the question of whether or not Medicaid recipients and providers are able to sue States that attempt to reduce reimbursement rates required by the Medicaid Act. The case arose when California, in an attempt to save money, reduced rates that it would pay doctors and hospitals participating in Medicaid. The federal requirement for Medicaid reimbursement rates is that payments must at least be high enough to entice healthcare providers to take Medicaid patients. More recently, Washington state doctors were victorious in a challenge to a state rule limiting Medicaid enrollees to three emergency room visits a year for conditions that the state labeled “non-emergent.” However, the judge’s order in that case was procedural in nature, and the Washington State Health Care Authority, the state’s Medicaid agency, is likely to initiate another rulemaking procedure in an attempt to reduce what the state deems unnecessary emergency room care for Medicaid enrollees by $70 million in two years.

State efforts to cut Medicaid costs are not new. While the federal government contributes half the cost of the program, Medicaid consumes 22% of the average state’s annual budget; this is more than states pay for education, transportation, and prisons. As we see downturns in the national economy, more individuals lose their jobs and become eligible for the program; and in times where the state sees less revenue from tax dollars, it is charged with paying more into their respective programs. These effects are far reaching and are impacting states all over the country. Reportedly, Massachusetts no longer covers restorative dental care and dentures and Washington no longer covers eyeglasses or hearing aids. Delaware is no different.

Currently, Medicaid covers almost 25% of Delaware’s population and some opine that our system is broken, with a $600 million bill this year alone and an expectation that more than 35,000 Delawareans will be newly eligible in fiscal year 2013. As reported by the Wilmington News Journal, the Delaware Commission on Medicaid Cost/Health Care Containment, a 22-member commission, recently met to vote on more than two dozen ideas meant to control the rising costs of the program. But after five months of debate, some are disappointed with how little was accomplished. To read the full article, visit http://www.delawareonline.com/article/20111215/BUSINESS13/112150326/Short-list-fixes-left-Medicaid.

Some of the Commission’s recommendations include:

• Taxing sugary drinks to raise money for Medicaid and discourage the consumption of such products
• Support for “medical homes” that enable better management of patient care
• Adopting a waiver plan for retired state employees
• Increasing the use of electronic prescriptions and medical records
• Adopting a reciprocity agreement with other states to attract more dentists to Delaware

Some of the ideas the Commission rejected include:

• Reducing reimbursement rates for lab fees
• Reducing reimbursement rates for non-urgent visits to the emergency room or limiting non-urgent visits to three per year
• Imposing standards on Medicaid recipients to reduce lifestyle choices such as smoking and setting standards for nutrition and exercise (Federal regulations forbid imposing higher costs for these reasons)

It is important for Delaware physicians to be on notice of legislation, rulemaking or any policy changes affecting Medicaid reimbursement. Additionally, in such cash-strapped times, it is more likely for the State to increase efforts to recover overpayments. Healthcare providers should be ready to respond to investigations and audits aimed at recovering Medicaid payments throughout the State. As more Delawareans become eligible for Medicaid, the State will continue to focus on how to cut costs and providers should be keenly aware of how such changes will affect their practice and patient care.